Adviniacare Orchard, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in East Providence, Rhode Island.
- Location
- 135 Tripps Lane, East Providence, Rhode Island 02915
- CMS Provider Number
- 415059
- Inspections on file
- 49
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 27 (3 serious)
Citation history
Health deficiencies cited at Adviniacare Orchard, Llc during CMS and state inspections, most recent first.
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when roof leaks allowed brown water to penetrate ceiling tiles and overhead light fixtures on a second-floor care area. Towels, buckets, and laundry carts were placed in hallways and outside rooms to collect actively leaking water, leaving floors wet and slippery while many cognitively impaired residents sat or ambulated nearby. The Maintenance Assistant acknowledged the leak had started the prior day and that he had not yet removed snow from the roof as instructed, while the Administrator and Director of Operations confirmed awareness of the worsening leaks but could not show evidence of effective immediate interventions. Authorities later found water inside the second-floor fire panel, which appeared tampered with, and ordered evacuation of residents after determining the environment was unsafe.
Surveyors found that biohazardous waste and sharps were stored in unlocked, unsecured rooms throughout multiple units, including a secured memory care unit, and in a room off the back entrance with the door partially open. Boxes labeled as infectious or biohazard waste were overflowing with sharps containers and red biohazard bags, with some sharps containers open and needles and IV lines with visible blood exposed, while residents were observed moving near these areas. Staff, including the Administrator, DNS, and Assistant Maintenance Director, acknowledged that the rooms were unlocked, that biohazardous waste remained on the units, and that the contracted waste removal company had stopped pickups due to non-payment, with no evidence of proper biohazard disposal for an extended period.
Surveyors found that biohazardous waste and sharps were stored in unlocked, unsecured rooms throughout the facility, including a memory care unit, despite a policy requiring sharps to be kept in locked, designated containers and areas. A room off the back entrance contained overflowing boxes and bags of infectious and biohazard medical waste with the door left partially open, and facility leadership acknowledged the room was unlocked and filled with biohazardous waste. On multiple units, surveyors observed overflowing sharps containers, an open sharps container with exposed needles, sharps containers placed on the floor, and IV lines with visible blood hanging from sharps containers, while residents were ambulating nearby. Facility representatives and the contracted waste vendor reported that biohazard waste removal services had been on hold for months due to non-payment, and records showed no licensed biohazard waste removal since that time.
The facility failed to properly manage and dispose of garbage, allowing trash bags, including those containing PPE gowns, to accumulate along the back entrance shared with the main kitchen and block exit doors and an exit ramp. A complaint and accompanying photographs showed that the garbage covered the platform and extended to the ground, obstructing fire exits. Interviews with the contracted garbage removal company and facility staff revealed that weekly garbage pickups had been suspended for several weeks due to non-payment, during which time the trash accumulated and blocked exit routes, creating a hazardous condition for residents.
The governing body failed to ensure effective oversight of waste management policies, resulting in unsecured biohazardous waste and accumulated garbage throughout the facility. A complaint and surveyor observations confirmed large amounts of trash, including bags with PPE gowns, blocking back exit doors and ramps, and multiple unlocked rooms containing overflowing boxes of sharps containers, open sharps containers with exposed needles, and IV lines with visible blood. The Administrator, DNS, and maintenance staff acknowledged that biohazard and garbage removal services had been suspended for months due to non-payment, and vendor representatives confirmed that pickups had been on hold, while emails showed the governing body had been informed that these accounts were on credit hold.
A resident with a history of falls was not assessed or monitored after falling from a wheelchair, and the incident was not documented in the medical record. Staff failed to perform required post-fall evaluations, neurological checks, or notify a provider, despite the resident later developing severe pain and being diagnosed with a spinal fracture. The facility's policies for fall management and significant change were not followed.
Two residents with chronic kidney disease on dialysis did not consistently receive their prescribed Sevelamer Carbonate as ordered, and their fluid restrictions were not maintained according to physician orders. Medication records showed multiple missed doses and instances where fluid intake exceeded prescribed limits. Interviews confirmed the medication was not always given as scheduled, and facility leadership could not provide evidence of compliance.
A resident with dementia and mobility issues experienced an unwitnessed fall and showed signs of a possible hip fracture. Although a STAT right hip X-ray was ordered, the facility did not obtain the X-ray within the expected timeframe, and staff did not notify the provider of the delay. The resident's condition worsened, leading to hospitalization where a hip fracture was confirmed. Staff interviews confirmed expectations for timely STAT X-rays and provider notification in case of delays, and the DON acknowledged ongoing issues with radiology service timeliness.
A resident did not have daily weights recorded as ordered by the physician, and there was no documentation that the physician was notified of the missed weights. The DNS was unable to provide evidence that the required daily weights were obtained.
A resident with heart failure and fluid restrictions was not provided the physician-ordered low sodium diet and received excess fluids from dietary staff, as meal tickets and tray contents did not align with prescribed orders. The dietitian confirmed the errors in both diet and fluid provision.
A resident with heart failure and respiratory diagnoses had a physician-ordered fluid restriction, but the facility failed to document actual fluid intake and output per shift, and water containers were found at the bedside against policy. Additionally, the resident's behavioral concerns noted in the care plan were not addressed in the social worker's assessment or documented in the medical record, and staff were unaware of these concerns.
A cracked glass panel on the main vestibule's inner door, covered with medical tape, was observed by surveyors. The DON confirmed the damage had been present for several weeks and could not provide evidence of a repair plan, resulting in a deficiency for not maintaining a safe and functional environment.
Surveyors found that multiple residents across all units did not have functioning call lights and were instead given hand bells to request assistance. Staff, including the DON and maintenance director, confirmed the ongoing issue, citing discontinued parts and a lack of timely replacement. Documentation showed that over 20 occupied rooms lacked call lights, and staff were often unsure how long the deficiency had persisted.
A resident with a history of falls and dementia fell and complained of back pain. A physician ordered immediate x-rays of the lumbar and thoracic spine, but only a single view of the lumbar spine was obtained. The RN on duty reported the x-ray as negative without noting the missing views. The resident continued to experience severe pain and was sent to the hospital, where new compression fractures were diagnosed. The facility could not provide evidence that the ordered x-rays were completed.
A resident admitted with a UTI and dementia did not receive the prescribed antibiotic, cephalexin, as ordered. Despite confirmation of the order with an on-call provider, the medication was neither transcribed nor administered. Interviews with staff, including an LPN and the DON, confirmed the oversight and highlighted the expectation that physician's orders should be followed.
A resident with a history of dementia and depression attempted suicide in an LTC facility. Despite the facility's policy requiring one-to-one supervision, the resident was only placed on frequent checks, and necessary notifications were not made. The resident's room contained potential hazards, and they were observed leaving the facility unattended twice on the same day. Surveillance footage and staff interviews confirmed these deficiencies.
A resident with a history of depression and PTSD attempted suicide in an LTC facility. Despite the facility's policy requiring one-to-one supervision, the resident was not adequately monitored and was left unsupervised with ligature risks in their room. The resident was able to leave the facility twice without supervision on the same day, and the DON was not informed until hours later.
A resident with multiple pressure injuries did not receive necessary wound care treatments as recommended by a wound physician. The facility failed to implement treatment orders for the resident's left lateral lower leg, right great toe, and left buttocks wounds for several days, despite recommendations. Interviews with staff revealed a lack of explanation for the oversight, and the DON acknowledged the absence of treatment orders until the issue was highlighted by a surveyor.
A survey identified deficiencies in food safety practices at a facility, including unclean kitchen equipment, unlabeled and undated food items, and staff not wearing required beard restraints. In the nourishment areas, various food items were not labeled or dated, and some were past their use-by date. Staff interviews confirmed these practices did not meet professional standards.
The facility failed to implement proper infection control measures, including Enhanced Barrier Precautions (EBP), for residents with multidrug-resistant organisms (MDROs). Staff were observed not using appropriate PPE, and necessary signage and precaution bins were missing. Additionally, improper handling of soiled linens was noted, contributing to the deficiency.
The facility failed to follow physician's orders for obtaining weekly weights for two residents, one with dysphagia and severe protein calorie malnutrition, and another with weakness and diabetes mellitus. Weights were not obtained on several occasions, and the Director of Nursing Services could not provide explanations or evidence for the missing weights.
A resident with a history of DVT experienced new symptoms of pain and swelling in the left leg. Despite a STAT order for a venous doppler, the procedure was not completed, and the provider was not notified of the delay. Staff interviews revealed communication lapses, and the resident was eventually sent to the emergency department, where a hematoma or small abscess was found.
A resident with pressure ulcers did not receive wound care as ordered, leading to a deficiency. The LPN applied barrier cream instead of medihoney and failed to change dressings daily, as required by the physician's orders. The DON confirmed that orders should be followed.
A facility failed to communicate a resident's critically low potassium levels to the dialysis center, resulting in continued hypokalemia. The resident, with chronic kidney disease, was receiving hemodialysis. Despite a physician's order for STAT labs and potassium, the LPN did not include this information in the communication sheet due to unawareness of lab results. The DON could not provide evidence of communication to the dialysis center before surveyor intervention.
The facility did not complete annual performance reviews for several nurse aides as required. A review of personnel records showed that 4 out of 7 nurse aides did not have documented evaluations within the past 12 months. The DON could not provide evidence of these evaluations during an interview.
The facility failed to timely address pharmacy recommendations for two residents, resulting in deficiencies in medication management. One resident's Pravastatin dosage reduction was delayed over two months, and a Risperdal discontinuation trial was not implemented. Another resident's Valproic Acid serum level test was delayed, revealing a subtherapeutic level. The DON acknowledged these delays, which violated the facility's 14-day policy.
A resident with intact cognition was physically abused by their roommate, who had a history of behavioral issues and moderately impaired cognition. The incident involved biting and slapping, resulting in injury and required medical treatment. Staff intervened but the facility failed to provide evidence of sufficient protective measures to prevent the abuse.
The facility did not post the most recent survey results in an accessible area for residents, staff, and the public. Residents were aware of the State Inspection results but had concerns about accessing them. A sign indicated the survey book was available upon request, but the binder was outdated, missing the latest survey from April 2024. The Regional Director confirmed the oversight and acknowledged the need for updating and relocating the binder.
A resident with a history of mental health disorders and cognitive impairments successfully eloped from a facility multiple times due to inadequate supervision and failure to assess elopement risks. The facility did not follow its own policies on elopement and AMA discharge, resulting in a lack of proper documentation and interventions. The resident's care plan was not updated to reflect these incidents, and the physician was not informed in a timely manner.
Roof Leaks, Water Intrusion, and Compromised Fire Panel Create Unsafe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when active water leaks from the roof penetrated ceiling tiles and electrical fixtures on the second floor. Surveyors observed multiple areas on two second-floor units with towels on the floor that were saturated with brown-colored water, as well as waste and laundry baskets and buckets placed in hallways and outside resident rooms to collect water from active leaks. Water was seen leaking from ceiling tiles and overhead light fixtures, with visible water staining on numerous ceiling tiles and wall surfaces. Floor surfaces were wet and slippery, particularly around the water collection buckets. Many residents, including those with mild to severe cognitive impairments, were observed sitting or ambulating near the active leaks and containers collecting water. During interviews, the Maintenance Assistant acknowledged the roof leak, stated it had started the day prior, and reported he had been instructed to remove snow from the roof to prevent continued leaking but had not yet done so. The Administrator acknowledged that the leaks had become progressively worse throughout the morning and that the facility was in the process of obtaining a quote to repair the roof. The Director of Operations confirmed awareness that the leaking water was coming from the roof and that a contractor had been called to assess and fix the damage, but he could not provide evidence of any immediate interventions implemented to ensure a safe, functional, sanitary, and comfortable environment. Subsequent evaluations by external authorities identified water inside the second-floor fire panel, which appeared to have been tampered with, and led to the establishment of a fire watch and orders to evacuate first the second floor and then the entire facility due to the water damage, active leaks, and compromised conditions.
Unsecured Biohazardous Waste and Sharps Stored on Resident Units and at Facility Entrance
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible related to the storage and management of biohazardous waste and sharps. A community complaint reported that trash and biohazardous waste were blocking the back entrance and that such waste was stored in unlocked, unsecured rooms. Surveyors observed a room off the back entrance with the door half open containing multiple boxes labeled “Infectious Waste” and “Biohazard Medical Waste,” overflowing with sharps containers and red biohazard bags filled with sharps containers, with additional red bags on the floor extending to the doorway and visible from outside the room. These observations were repeated later the same morning, again with the door half open and the same unsecured biohazardous waste present. Further observations on resident units showed that biohazardous waste and sharps were stored in unlocked and unsecured rooms where residents resided, including a secured memory care unit. On one unit, a box was overflowing with sharps containers, with five additional sharps containers on top, including one open container with exposed needles and other sharp objects. On another unit, boxes were overflowing with sharps containers with nine additional containers on top. On a third unit, fourteen sharps containers were observed on the floor, along with multiple IV lines visibly containing blood hanging from the sharps containers. On the memory care unit, a box was overflowing with sharps containers with five additional containers on top. During these observations, multiple residents were seen ambulating and self-propelling near these unsecured rooms. Interviews confirmed that the rooms were unlocked and contained biohazardous waste and sharps, and that the waste had not been removed from the units. The Assistant Maintenance Director acknowledged that the back entrance room was filled with biohazardous waste and unlocked, and stated that the contracted biohazard waste removal company had not picked up waste due to non-payment. A representative from the waste removal company reported that services had been on hold since non-payment and that the last pickup occurred months earlier, which was consistent with facility records showing no biohazardous waste removal since that time. The Administrator stated she was aware of the biohazardous waste disposal issues upon being hired and acknowledged that waste was not disposed of appropriately due to non-payment, and was unable to provide evidence that the residents’ environment remained as free of accident hazards as possible related to the storage of biohazardous materials.
Unsecured and Improperly Stored Biohazardous Waste and Sharps
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program related to the storage, security, and disposal of biohazardous waste and sharps. A community complaint reported that trash and biohazardous waste were blocking the back side of the building and that such waste was stored in unlocked, unsecured rooms. Surveyors observed, off the back entrance, a room with the door half open containing multiple boxes labeled "Infectious Waste" and "Biohazard Medical Waste" overflowing with sharps containers and red biohazard bags, with additional red bags and sharps containers on the floor extending to the doorway and visible from outside the room. The facility’s policy on storage of sharps required all sharps to be stored and secured in designated locked containers and areas at all times when not in use, and not to be handled by residents with functional or cognitive limitations. During subsequent observations, in the presence of the Administrator and the Assistant Maintenance Director, the same back entrance room was again found half open and filled with biohazardous waste, and both individuals acknowledged that the room was unlocked and contained biohazardous waste. The Assistant Maintenance Director stated that the contracted biohazard waste removal company had not picked up the waste due to non-payment by the facility. A representative from the contracted biohazard waste removal company confirmed that services had been placed on hold months earlier due to non-payment and that the last biohazardous waste removal had occurred in late May of the previous year. Review of facility records did not show evidence of any licensed biohazardous waste removal company being on site for waste removal and disposal since that time. Surveyors also observed unsecured biohazardous waste and sharps containers on multiple resident units, including a secured memory care unit. On one unit, a box was overflowing with sharps containers, with additional sharps containers on top, including one open container with exposed needles and other sharp objects. On another unit, boxes were overflowing with sharps containers, with multiple additional containers stacked on top. On the Cortland Unit, fourteen sharps containers were observed on the floor, along with multiple IV lines visibly containing blood and hanging from the sharps containers. On the memory care unit, a box was overflowing with sharps containers with additional containers on top. The DNS acknowledged that these unit rooms were unlocked and contained sharps containers with biohazardous waste and could not provide evidence that sharps containers were stored in secured areas not accessible to residents. During these observations, multiple residents were seen ambulating and self-propelling near the unsecured rooms, including on the secured memory care unit housing residents with cognitive impairment.
Failure to Manage Garbage Resulting in Blocked Exit Routes
Penalty
Summary
The facility failed to ensure proper disposal and management of garbage, resulting in a significant accumulation of trash at the back of the building that obstructed exit routes. A community-reported complaint to the Rhode Island Department of Health alleged that large amounts of trash were blocking the entire back side of the facility, including exit doors used as fire exits. Photographs from the complainant showed multiple black and white trash bags, including bags containing yellow personal protective gowns, piled along the back entrance shared with the main kitchen. The garbage covered the entire platform surface, extended to the ground below, and blocked the exit ramp, with multiple large garbage bins filled to capacity. Interviews and record review revealed that the contracted garbage removal company had placed services on hold after non-payment by the facility, with the last pickup occurring in late November and not resuming until early January. The representative from the garbage removal company confirmed that weekly Thursday pickups had been suspended due to non-payment. The Assistant Director of Maintenance acknowledged that garbage had not been picked up during this period and confirmed that the photographs accurately depicted the accumulation of garbage and blocked exit routes. The Administrator also acknowledged the photographs showing the large accumulation of garbage at the back entrance. When the surveyor later observed the back entrance, no garbage accumulation was present and exit routes were unobstructed, leading to a determination of past noncompliance.
Governing Body Failure to Ensure Safe Biohazard and Garbage Management
Penalty
Summary
The governing body failed to ensure effective implementation and oversight of policies for waste management and overall facility operations, resulting in serious deficiencies in the disposal and management of biohazardous waste and general garbage. The facility assessment stated that the physical environment and resources, including waste and hazardous waste management, were to be reviewed to ensure resident safety and well-being. However, a community complaint reported that large amounts of biohazardous waste were stored in unsecured rooms and that garbage was blocking the entire back side of the facility, including exit doors, making fire exits unavailable for residents in an emergency. Surveyor observations confirmed extensive accumulations of garbage and unsecured biohazardous waste. Photographs from the complainant showed large amounts of trash bags, including bags containing yellow personal protective gowns, blocking exit doors at the back entrance shared with the main kitchen, covering the entire platform, extending to the ground, and obstructing the exit ramp. On-site, surveyors observed a room off the back entrance with the door half open, containing multiple boxes labeled "Infectious Waste" and "Biohazard Medical Waste" overflowing with sharps containers and red biohazard bags, with additional red bags and sharps containers on the floor extending to the doorway and visible from outside the room. The Administrator and Assistant Maintenance Director acknowledged that the room was unlocked, filled with biohazardous waste, and that the contracted biohazard waste removal company had not removed the waste due to non-payment by the facility. Further observations on multiple units, in the presence of the DNS, revealed additional unsecured storage of biohazardous waste and sharps containers. On one unit, a box was overflowing with sharps containers, with several more on top, including one open container with exposed needles and other sharps. On other units, boxes were overflowing with sharps containers, and on one unit fourteen sharps containers were on the floor, with IV lines visibly containing blood hanging from the containers. The DNS acknowledged that these rooms were unlocked and contained biohazardous waste that had not been removed due to non-payment to the waste removal company by the facility owner. Representatives from the contracted biohazard and garbage removal companies confirmed that services had been placed on hold months earlier due to non-payment, and records showed no biohazardous waste removal since May of the prior year and no garbage removal for several weeks. Email communications showed the Administrator had informed the Regional Director of Operations that both accounts were on credit hold, and the Administrator acknowledged that the corporate governing body, which authorizes payments, was aware that these services were suspended due to non-payment.
Failure to Assess and Document Post-Fall Care
Penalty
Summary
A resident with a history of unsteadiness and falls was involved in an incident where they fell from their wheelchair to the floor. The fall occurred on a Friday, and both the resident and a nursing assistant confirmed the event. Despite this, there was no documentation of the fall in the resident's medical record, nor was there evidence of an assessment, initial or ongoing vital signs, neurological checks, or monitoring for latent injury as required by facility policy. The assigned nurse did not question the resident about the incident, did not perform an assessment, and did not notify the provider. The resident began experiencing significant pain the day after the fall, which escalated to severe back pain by Sunday. The resident was eventually sent to the hospital, where a compression fracture of the L2 vertebrae was diagnosed. Documentation showed that the resident received pain medication for increasing pain, but there was no record of post-fall evaluation or provider notification until the resident's pain became excruciating and they were unable to get out of bed. Interviews with staff and the Director of Nursing confirmed that the incident met the facility's definition of a fall and that required post-fall procedures were not followed. The facility was unable to provide evidence of any evaluation or provider notification following the fall, in direct violation of their fall management and significant change policies.
Failure to Administer Dialysis Medications and Enforce Fluid Restrictions
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received services consistent with professional standards of practice, specifically regarding the administration of Sevelamer Carbonate and adherence to fluid restrictions. For two residents with chronic kidney disease on dialysis, physician orders specified Sevelamer Carbonate to be administered three times daily with meals and set strict daily fluid restrictions. Medication Administration Records (MAR) revealed multiple missed doses of Sevelamer for both residents, often documented as the resident being absent or with no evidence of administration at the scheduled times. Additionally, records showed that both residents exceeded their prescribed fluid intake on several occasions, surpassing the limits set by their physicians. Resident interviews confirmed that the medication was not consistently administered as ordered, with one resident stating that Sevelamer was usually not given before meals as prescribed. The Director of Nursing Services was unable to provide evidence that the medication was administered as ordered or that fluid restrictions were consistently followed. These findings were based on record reviews, resident and staff interviews, and direct observation of facility documentation.
Failure to Obtain Timely STAT X-ray Following Resident Fall
Penalty
Summary
The facility failed to provide or obtain timely radiology services for a resident who sustained an unwitnessed fall and exhibited symptoms suggestive of a hip fracture, including right groin pain and a leg length discrepancy. A STAT right hip X-ray was ordered by the provider, and the resident was placed on bed rest pending results. Despite the STAT order, the X-ray was not performed within the expected timeframe, and the contracted radiology company did not provide a technician promptly. Nursing staff communicated with the resident about the pending X-ray and contacted the radiology company, but the X-ray was still not completed. Over the following day, the resident developed additional symptoms, including malaise, fever, and hypoxia, and experienced significant pain during care. The provider was updated about the resident's deteriorating condition, and the resident was eventually sent to the hospital, where a hip fracture was confirmed. Interviews with staff revealed that a STAT X-ray should be performed within four hours and that the provider should be notified if there are delays. The DON acknowledged that staff did not notify the provider of the delay in obtaining the X-ray, resulting in prolonged pain and hospitalization, and also stated that timeliness of X-ray services had been an ongoing issue with the contracted company.
Failure to Follow Physician's Order for Daily Weights
Penalty
Summary
The facility failed to meet professional standards of quality by not following a physician's order to obtain daily weights for a resident. The physician's order, which began on 3/27/2025, required daily weights to be recorded. However, there was no documentation of weights being taken from 3/28/2025 through 4/1/2025. Additionally, there was no evidence that the physician was notified about the missed weights. During an interview, the Director of Nursing Services was unable to provide documentation that the daily weights had been obtained during this period.
Failure to Provide Physician-Ordered Therapeutic Diet and Fluid Restriction
Penalty
Summary
A resident admitted with acute and chronic respiratory failure and diastolic heart failure had a physician order for a Low Sodium Diet (2-4 grams of sodium) and a 2000 ml daily fluid restriction, with dietary staff to provide only 830 ml of that total. On review, the resident was served a lunch meal containing a double portion of ham, despite the tray ticket specifying 'No Ham' and a low sodium diet. The dietitian confirmed that the prescribed diet was not served and that the resident should have received baked chicken instead. Additionally, the resident's meal tickets for the day indicated that the dietary department provided a total of 1320 ml of fluids, exceeding the 830 ml limit set by the physician's order. The beverages listed and served at each meal surpassed the allowed dietary fluid allotment. The dietitian acknowledged that the dietary staff provided beverages as listed on the meal tickets, resulting in the resident receiving more fluids than prescribed.
Failure to Maintain Accurate Medical Records and Fluid Restriction Protocol
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards for a resident with a physician-ordered fluid restriction. Despite a clear order specifying the daily fluid limit and its distribution across nursing shifts and meals, surveyor observation found multiple water containers at the resident's bedside, contrary to facility policy prohibiting water pitchers at the bedside for residents on fluid restriction. Review of the Medication Administration Records (MAR) for the relevant months did not show documentation of the actual fluid amounts consumed per shift, only check marks, and the Director of Nursing Services (DNS) confirmed that intake and output were not accurately recorded as required by policy. The DNS was also unable to explain the presence of water containers at the bedside. Additionally, the facility did not ensure that the resident's medical record accurately reflected behavioral concerns identified in the care plan. While the care plan noted verbal expressions of anger and accusatory behaviors, the social worker's assessment did not address these issues, and there was no evidence in the record that these concerns were followed up on. Interviews with staff revealed a lack of awareness of the resident's behavioral concerns, and the DNS could not provide documentation that the medical record was complete or accurate regarding these issues.
Failure to Maintain Safe and Functional Entrance Door
Penalty
Summary
Surveyor observation revealed that the lower glass panel of the main vestibule's inner door was damaged, with approximately eight one foot by one-foot cracked glass segments. The cracked areas were covered with white medical tape. During an interview, the DON acknowledged the damage and stated that it had occurred three to four weeks prior to the survey. No evidence of a plan to repair the door was provided at the time of the survey. These findings indicate that the facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, as required.
Failure to Provide Functioning Call Light System for Residents
Penalty
Summary
The facility failed to ensure that a functioning call system was available in each resident's bathroom and bathing area, as required. Surveyor observations, record reviews, and staff interviews revealed that approximately 30 residents did not have functioning call lights and were instead provided with hand bells to communicate their needs to staff. This issue was confirmed by the Director of Nursing Services, who provided documentation indicating that 25 rooms were labeled as having no call light (NCL), with 21 of those rooms currently occupied. Multiple staff members across all four units acknowledged the absence of call lights in specific resident rooms and were either unaware of how long the issue had persisted or stated it had been ongoing for at least a month. Further investigation showed that the problem had been ongoing for months, with the Director of Maintenance confirming that the call light system required replacement due to discontinued parts and that call lights continued to fail one by one. Although a quote to replace the call light system on one unit had been approved, there was no evidence of a contract or project start date. The Administrator also acknowledged the ongoing nature of the issue and the fact that multiple residents were without call lights at the time of the survey.
Failure to Follow Physician's Orders for X-rays After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following a physician's orders for x-rays after a fall. The resident, who had a history of dementia, unsteadiness, and falls, fell and complained of lower back pain. A physician ordered immediate x-rays of the lumbar and thoracic spine, but only a single frontal view of the lumbar spine was obtained. The lateral view of the lumbar spine and the two views of the thoracic spine were not completed, and this information was not communicated to the provider. The RN on duty read the incomplete radiology report to the provider, indicating the x-ray was negative, without mentioning the missing views. The facility later reported to the on-call provider that the x-rays were obtained as ordered and were negative. The resident continued to experience severe pain and was eventually sent to the hospital, where a CT scan revealed new compression fractures. The facility was unable to provide evidence that the ordered x-rays were obtained, and the Radiological Technologist later stated he was unable to complete all the x-rays as ordered.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of a prescribed antibiotic. The resident, who was a new admission with diagnoses including a urinary tract infection (UTI) and dementia, was supposed to receive cephalexin (Keflex) 500 mg twice a day for two days as per the hospital's Continuity of Care document. This order was confirmed with the on-call provider, and a new order was obtained. However, the October 2024 Medication Administration Record did not show that the Keflex was transcribed or administered to the resident as ordered. During interviews, a Licensed Practical Nurse (LPN) acknowledged that the resident did not receive the antibiotic as ordered. A Nurse Practitioner indicated that she would expect the order to be completed if given by an on-call provider. The Director of Nursing Services also acknowledged that the physician's order for Keflex had not been transcribed or administered as ordered, and she expressed an expectation that physician's orders should be followed. This oversight represents a failure to adhere to professional standards of practice in medication administration.
Neglect Following Resident's Suicide Attempt
Penalty
Summary
The facility failed to protect a resident from neglect following a suicide attempt. The resident, who had a history of vascular dementia, depression, and PTSD, attempted suicide by wrapping a belt around their neck. Despite the facility's policy requiring one-to-one supervision and immediate notification of the physician and nursing administration, the resident was only placed on frequent checks, and the necessary notifications were not made. The family was also not informed until they called the facility after speaking with the resident. Staff interviews revealed that the resident was restless and awake during the night of the incident, and the belt was removed with the help of three staff members. However, the resident was not placed under one-to-one supervision as required by the facility's policy. Additionally, the resident's room contained potential hazards such as belts and cords, which were not removed despite the recent suicide attempt. The resident was observed leaving the facility unattended twice on the same day as the suicide attempt, indicating a failure to monitor their whereabouts. Surveillance footage confirmed these events, and staff interviews corroborated the lack of supervision and failure to follow the facility's policy. The DON was not informed of the incident until several hours later and was unaware of the policy requirements and the unsafe items in the resident's room.
Inadequate Supervision Following Resident's Suicide Attempt
Penalty
Summary
The facility failed to provide adequate supervision to a resident who attempted suicide, as evidenced by multiple lapses in following their own policy. The resident, who had a history of major depression, PTSD, and moderate cognitive impairment, attempted to hang themselves with a belt. Despite the facility's policy requiring one-to-one supervision following a suicide attempt, the resident was not placed under such supervision. Instead, staff only conducted frequent checks, which were not documented, and the resident was left unsupervised in their room with accessible ligature risks. The incident occurred during the early morning hours, and staff members, including the Night RN/Nursing Supervisor and Nursing Assistant, failed to implement the required one-to-one supervision. The resident was found with a belt around their neck, and it took three staff members to remove it. Despite this serious incident, the resident was not continuously monitored, and the facility's policy was not followed, as the charge nurse did not notify the physician or nursing administration immediately. Further failures were observed when the resident was able to leave the facility unsupervised twice on the same day. Surveillance footage showed the resident exiting the facility without staff supervision, indicating a lack of monitoring of their whereabouts. The Director of Nursing was not informed of the incident until several hours later, and there was no evidence of the facility taking immediate action to ensure the resident's safety, such as removing unsafe items from the resident's room or notifying the family promptly.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to provide necessary treatment and services to promote wound healing and prevent new ulcers from developing for a resident with multiple pressure injuries. The resident was readmitted to the facility with diagnoses including sepsis, pressure injuries to the left lateral lower leg, left buttocks, right great toe, osteomyelitis, and muscle wasting. A wound physician recommended daily treatment for the resident's left lateral lower leg pressure wound, but the facility did not implement this treatment for 19 days. Additionally, two new deep tissue injuries were identified on the resident's right great toe and left buttocks, with treatment recommendations made by the wound physician. However, these recommendations were not acted upon for 12 days. Interviews with facility staff revealed a lack of implementation of the wound physician's recommendations. The resident's physician stated that wound recommendations are typically followed, while the wound nurse, responsible for entering the recommendations into the system as orders, could not explain why the treatments were not implemented. The Director of Nursing Services acknowledged the absence of treatment orders for the resident's wounds until the surveyor brought it to the facility's attention.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility was found to have several deficiencies in food safety practices during a survey. In the main kitchen, a chef's knife and a can opener were observed with dried food residue, indicating they were not cleaned according to professional standards. Additionally, refrigerated ready-to-eat foods such as applesauce and mixed fruit were not labeled or dated, which is a requirement under the Rhode Island Food Code. Staff members in the kitchen were also observed handling food without wearing required beard restraints, which is necessary to prevent contamination. In the nourishment areas of different units, similar issues were identified. On the A Unit, a toaster was found with dried food debris, and several containers of thickened lemon-flavored water were open and undated, contrary to the manufacturer's instructions. On the B Unit, various food items, including a cheeseburger and burger patties, were not labeled or dated, and some shakes were past their use-by date. The C Unit also had undated food items and expired shakes, indicating a widespread issue with food labeling and storage across the facility. Interviews with staff members, including a Registered Dietitian and a supervisor, confirmed that the observed practices did not meet the facility's policies or professional standards. They acknowledged that all food and beverages should be dated when opened, expired foods should be discarded, and food equipment should be clean. The lack of adherence to these standards led to the deficiencies noted in the survey.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Enhanced Barrier Precautions (EBP) for four residents. Resident ID #84, who was diagnosed with MRSA, had wound care supplies improperly handled by an LPN, who used contaminated gloves to touch various items and intended to reuse these supplies for other residents. The Director of Nursing Services acknowledged that these supplies should not have been removed from the resident's room or reused. Resident ID #28, with a history of ESBL infection, did not have the required precaution signage or PPE bin outside their room. Staff members were observed providing care without the necessary PPE, and one staff member was unaware of the resident's need for enhanced precautions. The Infection Preventionist and DNS confirmed that enhanced barrier precautions should have been in place. Resident ID #42, with pressure ulcers, had signage and a bin for EBP, but a nursing assistant attempted to provide care without wearing a gown. The DNS confirmed that staff should wear appropriate PPE. Additionally, Resident ID #163, with a gastrostomy tube, lacked precaution signage and a PPE bin, and staff were unaware of the need for EBP. The facility also failed to follow proper infection control practices for handling soiled linens, as observed with Resident ID #92, where soiled linens were placed on the floor instead of in a bag.
Failure to Obtain and Document Weekly Weights
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not following physician's orders for obtaining weekly weights for two residents. Resident ID #53, who was readmitted with diagnoses including dysphagia and severe protein calorie malnutrition, had a physician's order for weekly weights starting in early May 2024. However, the facility did not obtain weights on several occasions, specifically on 5/14/2024, 5/21/2024, and 6/3/2024. The nursing progress note for 5/14/2024 indicated that the weight was not obtained, but did not provide a reason or document any further attempts to obtain the weight. During an interview, the Director of Nursing Services (DNS) could not explain the lack of documentation or provide evidence of the missing weights. Similarly, Resident ID #96, who was readmitted with diagnoses including weakness and diabetes mellitus, had a physician's order for an admission weight and weekly weights for four consecutive weeks. The facility failed to obtain weights on 6/10/2024 and 6/17/2024. The DNS was unable to provide evidence of these missing weights and acknowledged that staff should have followed the physician's orders. These failures indicate a lack of adherence to professional standards of practice in obtaining and documenting required resident weights.
Failure to Timely Execute STAT Order for Resident with DVT History
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with a history of deep vein thrombosis (DVT). The resident, who was readmitted with a diagnosis of acute embolism and thrombosis of deep veins in the right lower extremity, reported new symptoms of pain, redness, and warmth in the left leg. Despite these symptoms and a physician's order for a STAT venous doppler, there was no evidence that the provider was notified of the change in condition on the day it occurred, nor was the venous doppler completed as ordered. Interviews with staff revealed that the order for the venous doppler was not transcribed as STAT, and the provider was not informed of the delay. The resident's condition was not communicated to the nurse practitioner until two days later, and the medical director confirmed that a STAT order should have been completed the same day. The director of nursing services acknowledged the oversight only after it was brought to their attention by the surveyor. The resident was eventually sent to the emergency department, where a small complex fluid collection, likely a hematoma or small abscess, was found in the calf.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice to promote wound healing and prevent new ulcers from developing for a resident with pressure ulcers. The resident, who was admitted with Alzheimer's disease and pressure ulcers on the coccyx and left heel, had specific physician's treatment orders for wound care. These orders included applying medihoney followed by calcium alginate and covering with foam dressing for the left heel, and applying medihoney and bordered foam dressing for the coccyx, both to be done every evening shift. During a surveyor observation, it was found that the wound care was not performed as ordered. The LPN, identified as Staff E, removed a soiled dressing from the coccyx, cleansed the wound with normal saline, and applied barrier cream instead of medihoney, failing to cover the wound with the bordered foam dressing as ordered. Additionally, the dressings were not changed daily as required, as evidenced by the dressings being dated two days prior. Staff E admitted to being uncertain of the treatment order before providing care, and the Director of Nursing Services confirmed that physician's orders should be followed.
Failure to Communicate Critical Lab Values for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper communication and management of a resident's dialysis care, leading to a deficiency in providing safe and appropriate dialysis services. The resident, who was readmitted with acute kidney failure and chronic kidney disease, was receiving hemodialysis three times a week. A physician's order for STAT labs revealed a critically low potassium level, which was communicated to the physician, resulting in an order for a STAT dose of potassium. However, the communication of these critical lab values and the resident's change of condition was not effectively relayed to the dialysis center or nephrology, as evidenced by the Hemodialysis Communication Sheet. During the survey, it was discovered that the Licensed Practical Nurse responsible for completing the communication sheet was unaware of the resident's lab results and the Nurse Practitioner's progress note, leading to the omission of critical information. The Director of Nursing Services was unable to provide evidence that the facility had communicated the resident's critically low potassium level to the dialysis center before the surveyor's intervention. This lack of communication and coordination between the facility and the dialysis center resulted in continued hypokalemia for the resident.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete an annual performance review for every nurse aide at least once every 12 months, as required. This deficiency was identified during a record review and staff interview, which revealed that 4 out of 7 nurse aide personnel records lacked evidence of a completed annual performance evaluation. The affected staff members included Staff F, G, H, and I, with hire dates ranging from 2013 to 2022. During an interview with the Director of Nursing Services, conducted on June 26, 2024, at 10:45 AM, she was unable to provide documentation of a completed performance evaluation within the last 12 months for these employees. This indicates a lapse in the facility's adherence to regulatory requirements for staff performance evaluations.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for two residents, leading to deficiencies in medication management. For one resident, a recommendation to reduce Pravastatin dosage was made on April 9, 2024, but was not signed by the provider until June 20, 2024, and was not implemented until the surveyor's intervention. Additionally, a recommendation to trial discontinuation of Risperdal was signed on June 11, 2024, but was not acted upon. For another resident, a recommendation to obtain a Valproic Acid serum level within two weeks was signed on June 11, 2024, but the test was not conducted until June 26, 2024, after the surveyor's notice. The lab report indicated a subtherapeutic level of Valproic Acid, which was significantly below the therapeutic range. The Director of Nursing Services acknowledged the delay in addressing these recommendations, which were expected to be completed within 14 days according to facility policy.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. Resident ID #45, who was cognitively intact with a BIMS score of 15, was assaulted by their roommate, Resident ID #81, who had a moderately impaired cognition with a BIMS score of 11. The incident occurred when Resident ID #81, who had a history of behavioral problems, including swearing, agitation, and combativeness, bit Resident ID #45 on the cheek. This altercation was reported to the Rhode Island Department of Health, and the facility's records confirmed the occurrence of the abuse. The incident was documented in the facility's progress notes and investigation statements. Staff members, including a Nursing Assistant and a Licensed Practical Nurse, intervened to separate the residents during the altercation. Despite these efforts, Resident ID #81 continued to attempt to hit Resident ID #45. The facility's records indicated that Resident ID #45 experienced pain and required medical treatment for the bite injury, which included antibiotics and topical care. The Director of Nursing Services acknowledged the assault and the resulting injury to Resident ID #45. However, the facility was unable to provide evidence that they had effectively protected Resident ID #45 from abuse, as required by regulations. The lack of sufficient protective measures and the failure to evaluate the effectiveness of interventions for Resident ID #81's behavioral issues contributed to the deficiency in ensuring resident safety.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to post the results of the most recent survey in a readily accessible area for residents, staff, and the public. During a resident council task, residents expressed awareness of the State Inspection results but raised concerns about their accessibility. A surveyor observed a sign near the front desk indicating that the Department of Health Survey Book was available upon request in the receptionist's office. However, upon reviewing the facility's survey results binder, it was found that the last entry was from a survey conducted in December 2023, and it did not include the most recent survey results from April 2024. The Regional Director of Clinical Services confirmed that the binder was not updated to include the most recent surveys for 2024 and acknowledged that the survey results binder should be updated and placed in a readily accessible location.
Failure to Prevent Resident Elopement and Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assessment for a resident, identified as Resident ID #4, who successfully eloped from the facility on multiple occasions. The resident, who has a history of schizoaffective disorder, adjustment disorder, traumatic brain injury, developmental delay, mild intellectual disability, and type 2 diabetes mellitus, was not properly assessed for elopement risks, nor were appropriate interventions implemented. On one occasion, the resident eloped from a behavioral health appointment, and the facility assumed the resident left against medical advice (AMA) without following the proper discharge procedures. The facility's policy on elopement and AMA discharge was not adhered to, as evidenced by the lack of an elopement assessment and the absence of an AMA discharge order or documentation in the resident's clinical record. The resident's care plan did not reflect any assessment for elopement risks or interventions following the incidents. Additionally, the facility staff, including the Director of Nursing Services and the Regional Director of Nursing, were unable to provide evidence of a completed AMA discharge or an elopement risk assessment after the resident's unsupervised departure from the community provider's office. Further incidents occurred when the resident eloped from the facility on two consecutive days, following a verbal altercation with another resident. Despite these events, the facility failed to analyze the incidents or update the resident's care plan to address elopement behaviors. The resident's physician was not informed of these incidents until much later, and the facility did not conduct the necessary elopement behavior assessments, placing the resident at risk for serious injury, harm, impairment, or death.
Latest citations in Rhode Island
A cognitively impaired resident with dementia and severe BIMS impairment, care planned and ordered to wear a wander guard with regular placement and function checks, eloped from the facility after being last seen in an activity room with a visitor. Staff later could not locate the resident for dinner, and searches were initiated while the resident’s whereabouts were unknown for several hours. Witnesses, including the Activities Director, Receptionist, another resident’s family member, and the visitor, reported that the resident and visitor exited through the main entrance without a wander guard alarm sounding and without use of a door code. The visitor admitted driving the resident to the spouse’s home without notifying staff. EMS and hospital records documented that the resident had been missing for several hours, was confused, could not recall events, and reported severe throat and chest pain, arriving at the hospital with an ankle monitoring device in place. Upon the resident’s return, the facility discarded the original wander guard without testing its functionality and could not provide evidence of consistent monitoring per policy and physician orders, resulting in an Immediate Jeopardy situation.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment, documented exit-seeking behavior, and a care plan identifying high elopement risk and the use of a wander guard was inadequately supervised. Earlier in the day, an LPN observed the resident attempting to open an exit door and redirected the resident, who was later last seen in their room. The resident subsequently exited a secured unit through a stairwell door that only briefly alarmed and was not connected to the wander guard system, descended to a basement level, and left through an exterior door. Because wander guard sensors were only placed at elevators and not at exit doors or stairwells, the resident’s departure went undetected until a Code Orange was called and the elopement protocol initiated, after which staff located the resident off premises and returned the resident to the facility.
A cognitively intact resident with spinal stenosis and post-stroke hemiplegia/hemiparesis was discharged from the hospital with documented referrals to a spine center for evaluation and possible spinal steroid injections, which were reiterated in a later provider note citing ongoing lower extremity weakness. Despite these physician-ordered referrals and the resident’s repeated attempts to reach the appointment scheduler, the facility did not schedule or facilitate the neurosurgical consultation. The unit secretary, who was responsible for scheduling, reported being unaware of the referrals, and neither she nor the DON could provide any evidence that efforts were made to arrange the appointment, leading to a prolonged delay in the resident’s surgical follow-up.
A resident with dysphagia, autonomic dysfunction, seizure disorder, a G-tube, and dependence on staff for feeding had physician orders and a care plan requiring a minced and moist diet with thin liquids given by spoon only while upright. Video from a room camera showed a nurse providing thin liquids through a straw while the resident was lying down and continuing despite the resident coughing. Additionally, a physician ordered every-shift monitoring and documentation of vital signs, including lung sounds, O2 saturation, temperature, and signs of aspiration for seven days, but the MAR showed that required vital signs were not obtained on multiple shifts. The DON confirmed these deviations from physician orders and expected practice.
A resident with intact cognition and a history of hypertension used the call light for toileting assistance when a CNA entered the room and yelled statements such as not "playing games" and telling the resident to wait, causing the resident to become upset. A nursing supervisor heard the CNA yelling, went to the room, and observed the resident visibly upset, while an LPN’s written statement described the CNA’s tone as very rude and yelling about having been with another resident. The CNA later acknowledged speaking loudly to the resident, and during interviews, the administrator and DON could not demonstrate that the resident had been free from verbal abuse as required by the facility’s abuse prohibition policy.
A resident with Alzheimer’s disease receiving hospice services was observed by an RN to be grimacing, with swelling and bruising of the right ankle, and an x-ray later confirmed displaced fractures of the medial and lateral malleolus. Facility policy required that responsible family or legal representatives be notified within 24 hours of significant condition changes or injuries and that this notification be documented in the medical record. A NP documented the fracture findings and ordered that hospice and the resident’s representative be contacted, but there was no documentation that the representative was notified. In interviews, the resident’s representative reported learning of the injuries from hospice staff, the RN acknowledged not notifying the representative, and the DON could not provide evidence that immediate notification occurred, resulting in a deficiency for failure to notify the representative of a significant change in condition.
A resident with Alzheimer's disease, severe cognitive impairment, and non-ambulatory status, receiving hospice care, was found grimacing with swelling and bruising to the right ankle after being brought to the dining room. An x-ray later confirmed acute to subacute displaced fractures of both the medial and lateral malleolus, with no cause identified in the record, making it an injury of unknown origin. A hospice aide reported that during care, the resident became agitated and flailed while two CNAs held the resident's arms and legs, but care was not stopped and the nurse was not notified of the behavior. The RN on duty could not show that the injury of unknown origin was reported to RIDOH, and the DON acknowledged that the incident was not reported, resulting in a failure to report an alleged violation and injury of unknown origin as required.
A non-ambulatory hospice resident with severe cognitive impairment developed swelling and bruising of the right ankle after being taken to the dining room and receiving care in the room, during which the resident became agitated and flailed while a hospice aide and two CNAs continued care and physically held the resident’s arms and legs. An RN later noted the ankle changes, obtained an x-ray order from a provider, and imaging confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. The clinical record and interviews with the RN, DON, and NP showed that no thorough investigation was conducted into the origin of the injury, no potential causes were documented or identified, and no interventions to prevent further or potential injury were documented, despite regulatory requirements and a community complaint alleging lack of notification and unclear cause of the injury.
A resident with CHF, afib, moderate cognitive impairment, and low body weight was mistakenly given another resident’s clozapine 150 mg and melatonin 3 mg by a CMT who entered the wrong room and failed to verify identity, contrary to facility policy requiring multiple resident-identification checks. The resident did not receive ordered warfarin and metoprolol during this pass. Subsequently, the resident was found unresponsive with abnormal respirations, tachycardia, and hypoxia, required EMS intervention with suctioning, high-flow oxygen via BVM, and IV emergency cardiac medication, and was admitted to the hospital with altered mental status, profound hypothermia, pleural effusion, and aspiration pneumonia, later transitioning to comfort care and expiring. The DON was unable to show the resident was kept free from significant medication errors, and the Medical Director stated she expected correct medications to be given to the correct resident.
The facility failed to ensure that a CMT had demonstrated competency in resident identification during medication administration and did not complete the required quarterly medication aide evaluations. Despite only one documented evaluation and no evidence of competency in verifying resident identity, the CMT was scheduled to pass medications and entered the wrong room, administering clozapine 150 mg and melatonin 3 mg intended for another resident to a frail, elderly resident with CHF and Afib. The resident, who weighed 79.2 pounds, subsequently developed tachycardia, shortness of breath, altered mental status, profound hypothermia, a small pleural effusion, and aspiration pneumonia, was admitted to the hospital for comfort measures only, and later died. The DON acknowledged that quarterly evaluations were required and could not provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
Elopement of Cognitively Impaired Resident Despite Wander Guard Device
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary supervision and maintain an effective elopement prevention system for a cognitively impaired resident identified as an elopement risk. The resident had diagnoses including dementia, cognitive communication deficit, and anxiety disorder, and a Quarterly MDS showed a BIMS score of 4/15, indicating severe cognitive impairment. The resident’s care plan, initiated after prior attempts to leave the facility, required use of a wander guard bracelet, weekly assessment of the device’s functioning and battery status, and visual checks or supervision for safety. Physician orders directed staff to check placement of the Tektone wander guard bracelet every shift and to check its functionality weekly. Documentation on the March Treatment Administration Record indicated the device was in place on the day of the incident and that its functionality had been checked and found operational several days earlier. On the day of the elopement, staff observed the resident wearing the wander guard bracelet in the activities room during a bingo activity in the mid-afternoon. An LPN reported last seeing the resident in the activity room seated with a visitor and wearing the wander guard. Later, when the LPN attempted to escort the resident to dinner, the resident could not be located, and a subsequent call to the resident’s spouse confirmed that the spouse did not have the resident and was unaware the resident was missing. The facility’s elopement protocol was then initiated, and staff, along with law enforcement, conducted searches of the building and surrounding community. During this time, staff and management did not know the resident’s whereabouts for several hours. Interviews and witness accounts established that the resident exited the facility through the main entrance with a visitor. The Activities Director stated that she did not see the resident or visitor leave and did not hear a wander guard alarm at the exit. The Receptionist reported seeing the resident and a visitor walking toward the main entrance and also did not hear an alarm. A visitor later admitted that she removed the resident from the facility at the resident’s request to go home, drove the resident to the spouse’s house, dropped the resident off, and left without notifying staff; she stated that the wander guard alarm did not sound when they exited and that she had never been given a door code. A family member of another resident reported seeing the visitor leave with the resident through the main entrance without hearing an alarm or seeing a code entered. The resident ultimately arrived at the spouse’s home with a sandwich in hand, appeared confused, and could not explain how they had gotten there. EMS and hospital records documented that the resident had been missing from the facility for several hours, could not recall their whereabouts, and reported severe throat and chest pain; the hospital record also noted that the resident arrived with an ankle monitoring device in place. Following the resident’s return, the facility did not evaluate or test the wander guard device that had been in use at the time of the elopement. A Regional Nurse documented that a new wander guard device was applied to the resident’s left ankle, and later acknowledged in interview that the original device had been discarded without assessment. The Regional Administrator and Regional Nurse were unable to provide evidence that the previous device had been checked or tested for functionality upon the resident’s return. The Administrator stated that it was unclear whether the wander guard system had failed, whether an alarm had sounded without staff response, or whether a visitor had entered a door code, and confirmed that visitors should not have the door code. The facility was also unable to provide documentation confirming that staff consistently monitored the resident in accordance with facility policy and physician orders. These failures resulted in the resident leaving the facility unsupervised for approximately six hours while staff were unaware of the resident’s whereabouts, placing the resident at risk for serious injury, serious harm, serious impairment, or death, and constituted a situation of Immediate Jeopardy.
Failure of Elopement Prevention and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and maintain an effective elopement prevention system for a resident assessed as a high elopement risk. The resident had Alzheimer’s disease, dementia, severe cognitive impairment (BIMS score of 00), a documented history of exit-seeking behaviors, and a care plan identifying high elopement risk, prior elopements, recent attempts to leave, verbalizations about leaving, and wandering behavior requiring a wander guard. On the morning of the incident, an LPN observed the resident attempting to open the unit exit door at approximately 9:30 AM; the resident was redirected and escorted back to the dining room. The resident was last seen in their room at approximately 10:00 AM. Despite residing on a secured unit and wearing a wander guard, the resident eloped from the unit via a stairwell door that alarmed when opened but stopped alarming after the door closed and after a period of time. The wander guard system was configured so that sensors were only located at the elevators and did not detect the resident at the unit exit doors or stairwell. The resident used the stairwell to descend several flights to the basement level and exited through a basement exterior door, leaving the building undetected. A Code Orange was not called and the elopement protocol not initiated until approximately 11:20 AM, at which time the resident had already traveled off premises and was later observed walking along a main road and crossing a four-lane street before being located and returned to the facility at approximately 11:45 AM.
Failure to Arrange Neurosurgical Follow-Up for Resident With Spinal Stenosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services were provided in accordance with professional standards of quality for a resident admitted with spinal stenosis and post-stroke hemiplegia/hemiparesis. The resident was admitted in October 2025 with diagnoses including spinal stenosis and left-sided weakness following a stroke. A Continuity of Care - Post-Acute Facility document dated 10/24/2025 indicated that, upon hospital discharge, a referral to a spine center was placed to evaluate the need for spinal steroid injections. A subsequent provider progress note dated 11/17/2025 documented the resident’s ongoing chronic lower extremity weakness related to lumbar disc protrusions and reiterated the need for outpatient neurosurgical follow-up, with an additional referral placed at that time. Record review and interviews showed that, despite these clear and repeated physician-ordered referrals, the facility did not schedule or facilitate the required neurosurgical consultation. The resident, who had a Brief Interview for Mental Status score of 14/15 indicating cognitive intactness and ability to express needs, reported making multiple unsuccessful attempts to contact the facility’s appointment scheduler to obtain the neurosurgical consultation for spinal injections. During an interview, the Unit Secretary responsible for scheduling appointments stated she was unaware of the referrals, and neither she nor the Director of Nursing Services could provide evidence that any efforts were made to arrange the neurosurgical appointment. A community complaint alleged that the resident waited approximately five months without resolution of the needed surgical follow-up appointment.
Failure to Follow Physician Orders for Dysphagia Management and Vital Sign Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice and followed physician orders for a resident with significant swallowing difficulties and other complex medical conditions. The resident, admitted with diagnoses including seizure disorder, autonomic dysfunction, presence of a gastrostomy tube, bilateral upper extremity contractures, and dysphagia, was dependent on staff for eating. A physician’s order dated 1/6/2026 specified a house diet with minced and moist texture and thin liquids to be provided by spoon only. The care plan initiated on 12/4/2024 also identified swallowing difficulty and included an intervention to provide thin liquids via spoon. A community complaint and video footage from the resident’s room showed that during an overnight shift, a nurse gave the resident a drink using a straw while the resident was lying down and continued to provide liquids while the resident was coughing, contrary to the physician’s order and care plan. The DON confirmed, after reviewing the video, that the nurse provided thin liquids with a straw while the resident was not upright and continued despite the resident’s coughing. The facility also failed to follow a physician’s order related to monitoring for possible aspiration. A physician’s order dated 3/19/2026 directed staff to obtain and document the resident’s vital signs, including lung sounds, oxygen saturation, temperature, and signs and symptoms of aspiration such as coughing or runny nose, every shift for seven days. Review of the March 2026 Medication Administration Record showed that vital signs were not obtained during the 3:00 PM–11:00 PM and 11:00 PM–7:00 AM shifts on 3/23/2026, and the 11:00 PM–7:00 AM shift on 3/24/2026. In an interview, the DON stated she expected vital signs to be obtained and documented each shift as ordered and acknowledged that the facility failed to ensure physician orders were followed for this resident.
Failure to Protect a Resident From Verbal Abuse by Nursing Assistant
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a nursing assistant. The resident was admitted with diagnoses including hypertension and had an admission MDS Brief Interview for Mental Status score of 15/15, indicating intact cognition. On the evening in question, after the resident used the call light for toileting assistance, Nursing Assistant Staff A entered the room and yelled, "I'm not playing games with you tonight, you keep pressing the call light, and I told you to wait." The resident reported being upset by this interaction. A Nursing Supervisor, Staff B, who was on duty at the time, responded to the resident’s room after hearing Staff A yelling and observed the resident to be visibly upset. An LPN, Staff C, provided a written statement indicating she heard Staff A speaking in a very rude tone and yelling, "I told you to wait, I was with another resident." Staff A’s own written statement acknowledged that she spoke back to the resident loudly. During an interview with the Administrator and the Director of Nursing Services, they acknowledged the findings and were unable to provide evidence that the resident was free from verbal abuse during this incident, in contrast to the facility’s abuse prohibition policy defining verbal abuse as disparaging or derogatory oral, written, or gestured language within a resident’s hearing.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative of a significant change in condition, specifically an injury of unknown origin resulting in right ankle fractures. The facility’s policy dated 10/19/2023 requires responsible family members or legal representatives to be notified as soon as possible, or within 24 hours, of any changes in the resident’s condition, including significant physical changes and any accidents resulting in injury, with documentation of such notification in the medical record. The resident, admitted in October 2025 with Alzheimer’s disease and receiving hospice services, was observed on 3/9/2026 by an RN to be grimacing after being brought to the dining room, and further assessment revealed swelling and bruising of the right ankle. An x-ray was ordered and later confirmed acute to subacute fractures of the medial malleolus with displacement and a moderately displaced fracture of the lateral malleolus. A subsequent progress note by a nurse practitioner documented the fracture findings and included an order to contact hospice and the resident’s representative to review the results. However, record review did not show any evidence that the resident’s representative was notified by the facility of the injuries, nor was there documentation of such notification in the medical record as required by policy. During interviews, the resident’s representative stated that they were not notified by the facility and instead learned of the injuries from hospice staff. The RN who first identified the bruising and swelling acknowledged that she did not notify the resident’s representative. The Director of Nursing Services was unable to provide evidence that the resident’s representative was immediately notified when the injuries were identified, confirming the failure to follow the facility’s notification policy.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the Rhode Island Department of Health (RIDOH) for a resident with Alzheimer's disease who was non-ambulatory, dependent on staff for all transfers, and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and was later observed grimacing, with swelling and bruising to the right ankle. An x-ray obtained that evening confirmed acute to subacute fractures of both the medial and lateral malleolus with displacement. A subsequent nurse practitioner note documented the fracture findings and included an order to contact hospice and the resident's representative, but the clinical record did not identify a cause for the injury, classifying it as an injury of unknown origin. Record review also failed to show that this injury of unknown origin was reported to RIDOH. During interviews, a hospice aide reported that after lunch she provided care to the resident in the room, accompanied by two CNAs. She stated the resident was not in discomfort before care, but became agitated during care and flailed upper and lower extremities, while one CNA held the resident's legs and another held the resident's arms; she did not stop care or notify the nurse of the resident's behavior. After care, the resident was transferred to a chair and returned to the dining room, and the aide later learned of the swollen ankle after returning from lunch, without knowing how the injury occurred. The RN on duty at the time of injury identification was unable to provide evidence that the injury of unknown origin was reported to RIDOH, and the Director of Nursing Services acknowledged that the facility did not report the injury to RIDOH, confirming the failure to report the alleged violation and injury of unknown origin as required.
Failure to Investigate Injury of Unknown Origin and Identify Cause of Ankle Fractures
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin for a non-ambulatory resident with Alzheimer’s disease who was dependent on staff for all transfers and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and later exhibited grimacing, with swelling and bruising noted to the right ankle. An x-ray obtained the same day confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. Although the nurse on duty notified the provider and obtained the x-ray order, the clinical record lacked documentation of any investigation into how the injury occurred, any determination or discussion of potential causes, or identification of the origin of the fractures. Surveyor interviews revealed that a hospice aide, accompanied by two CNAs, had taken the resident to the room after lunch to provide care. During care, the resident, who had not shown discomfort beforehand, became agitated and flailed upper and lower extremities while one CNA held the resident’s legs and another held the resident’s arms; care was continued despite the agitation, and the nurse on duty was not notified of this behavior. After care, the resident was transferred to a chair and returned to the dining room, and the hospice aide later learned of the swollen ankle but did not know how the injury occurred. The RN who discovered the swelling and bruising, the DON, and the NP all acknowledged there was no thorough investigation, no documentation establishing the origin of the injuries, and no evidence of implemented measures to prevent further or potential injury, and the facility could not provide investigative findings or evidence of required reporting.
Fatal Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a Certified Medication Technician (CMT) administered another resident’s medications without verifying identity. On the evening medication pass, the CMT, identified as Staff A, entered the wrong room and gave clozapine 150 mg and melatonin 3 mg, which were prescribed for a different resident, to Resident ID #1. This administration occurred despite a facility policy requiring staff to verify resident identity using methods such as checking an identification band, reviewing a photograph attached to the medical record, and, if necessary, confirming identity with other personnel. All patient identifiers were missed, and the resident did not receive his or her regularly scheduled medications, including warfarin 0.5 mg and metoprolol 12.5 mg. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. A recent MDS assessment showed moderately impaired cognition with a Brief Interview for Mental Status score of 10 out of 15. The resident weighed 79.2 pounds, and the provider documented that the clozapine dose administered in error was a significant concern given the resident’s small body habitus. Record review confirmed there were no physician orders for clozapine 150 mg or melatonin 3 mg for this resident. Following the medication error, progress notes documented that late on the night of the error, the LPN (Staff B) recorded that the resident had received another resident’s medications and had missed his or her own scheduled warfarin and metoprolol. The next morning, staff found the resident unresponsive with abnormal breathing, pale skin, a heart rate of 136 bpm, and an oxygen saturation of 90%, prompting transfer via EMS. EMS records described the resident as unresponsive with audible gurgling, excessive oral secretions requiring suctioning, a fast and irregular heart rate between 150–190 bpm, and severely depressed respirations requiring bag-valve-mask support and IV emergency heart medication. Hospital records documented elevated heart rate, shortness of breath, altered mental status, profound hypothermia, a chest x-ray showing a small left pleural effusion and aspiration pneumonia, and subsequent transition to end-of-life care, with the resident expiring several days later. During interviews, the DON could not demonstrate that the resident was kept free from significant medication errors, and the Medical Director stated she would have expected the correct medications to be administered to the right resident.
Failure to Ensure CMT Medication Competency and Required Quarterly Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Certified Medication Technician (CMT) had the required competencies and quarterly evaluations to safely administer medications, as required by Rhode Island regulations. State regulations mandate that medication technicians must complete a State‑approved course, demonstrate competency in drug administration, and receive quarterly evaluations by the Director of Nursing (DON) or RN designee, with documentation placed in personnel files. The facility’s own assessment stated that department‑specific training and competencies are completed throughout employment to ensure staff can safely and competently provide the required care. However, review of the CMT’s personnel record showed she was hired as a CMT/Nursing Assistant and had only one medication administration evaluation since hire, with no evidence of the four required quarterly evaluations. Record review of the CMT’s “Medication Administration Competency” document showed no evidence that she had demonstrated competency in identifying a resident prior to medication administration. Despite this, she was scheduled to administer medications periodically. On the evening in question, the CMT entered the wrong room and administered medications intended for another resident to Resident ID #1, without verifying the resident’s identity and missing all patient identifiers. The medications administered in error included clozapine 150 mg and melatonin 3 mg, which were prescribed for another resident. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. Following the medication error, a provider note documented that the CMT had administered the wrong medications by entering the wrong room and failing to verify identity, and that the clozapine dose was of significant concern given the resident’s low body weight of 79.2 pounds. The resident subsequently presented to the hospital with elevated heart rate, shortness of breath, and altered mental status, was found to have profound hypothermia, a small left pleural effusion, and aspiration pneumonia, and was admitted for inpatient comfort measures only. The resident later expired. The DON acknowledged that medication aide evaluations are required at least quarterly and was unable to provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
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